May 2011 Data Brief COMMISSION ON A HIGH PERFORMANCE HEALTH SYSTEM Health Care Opinion Leaders’ Views on Health Reform and the Role of States Kristof Stremikis, Karen Davis, Rachel Nuzum, and Edward L. Schor The mission of The Commonwealth ABSTRACT: When asked about the relative power of states and the federal government Fund is to promote a high performance over health reform, seven of 10 leaders in health care and health care policy favor the bal- health care system. The Fund carries ance set by the Affordable Care Act or more authority for the federal government, accord- out this mandate by supporting ing to a Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey. A independent research on health care issues and making grants to improve majority of leaders supports granting more federal authority over health insurance market health care practice and policy. Support rules and provider payment methods, while just two of 10 favor granting states more power for this research was provided by over the individual mandate provision contained in the law. Survey respondents are con- The Commonwealth Fund. The views cerned with several barriers to successful implementation of the act, including the current presented here are those of the authors fiscal situation and budgetary pressures in many states. Six of 10 leaders support creating and not necessarily those of The a federal health insurance exchange in addition to state exchanges, and more than 80 per- Commonwealth Fund or its directors, officers, or staff. cent support allowing states to implement key provisions ahead of the original timelines outlined in the law.      OVERVIEW For more information about this study, The Affordable Care Act has the potential to significantly transform the please contact: American health care system through a mix of public and private coverage Kristof Stremikis, M.P.P. 1 expansion and provider payment reform initiatives. The law creates several new Senior Research Associate The Commonwealth Fund requirements for states, including expansion of Medicaid eligibility, creation of ks@cmwf.org state-based health insurance exchanges, and increased regulation of private health insurance industry practices. The federal government, in turn, is primarily responsible for partnering with states in coverage expansion efforts, rapidly test- ing and spreading new provider payment methods, and supporting initiatives that To learn more about new publications seek to transform the health care delivery system. when they become available, visit the Fund's Web site and register to receive The latest Commonwealth Fund/Modern Healthcare Health Care Fund e-mail alerts. Opinion Leaders Survey asked experts in the field about the role of states and the Commonwealth Fund pub. 1506 federal government under the Affordable Care Act. When asked about the rela- Vol. 8 tive power of states and the federal government over health reform, 41 percent of 2T he  C ommonwealth F und health care opinion leaders think the federal govern- place the nation on a path to a high performance health 4 ment should have more authority and 29 percent favor system that works for all Americans. the balance set by the Affordable Care Act. On many features of health reform, opinion leaders lean toward The Health Care Opinion Leaders Survey more federal authority. Half of leaders support a stron- The Commonwealth Fund and Modern Healthcare ger federal role regarding health insurance market recently commissioned Harris Interactive to solicit the rules and provider payment methods. Only two of 10 perspectives of a diverse group of health care experts favor granting states more power over the individual on health reform and the role of states under the mandate provision contained in the law. Survey Affordable Care Act. The 203 individuals who took respondents are concerned with several barriers to suc- part in the survey—the 25th in a continuing series of cessful implementation of the act, including the cur- surveys assessing the views of experts on key health rent fiscal situation and budgetary pressures in many policy issues—represent the fields of academia and states. Six of 10 leaders support creating a federal research; health care delivery; business, insurance, and health insurance exchange option in addition to state other health industries; and government, labor, and exchanges, and more than 80 percent support allowing advocacy groups (see Methodology, Appendix A for states to implement key provisions ahead of the origi- detailed demographic information). Respondents were nal timelines outlined in the law. asked for their perspective on health reform and states Many of these views are in line with the rec- from April 6 to May 3, 2011. ommendations of the Commonwealth Fund Commission on a High Performance Health System, Opinion leaders either lean toward increased federal which has a mission to promote better access, authority or say the law strikes the right balance improved quality, and greater efficiency across the between state and federal power. 2 U.S. health care system. The Commission has con- When asked about the relative power of states and the cluded that meaningful reform of the health system federal government over health reform, 41 percent of will require a pragmatic mix of public and private ini- health care opinion leaders think the federal govern- tiatives that extend affordable insurance coverage to ment should have more authority and 29 percent favor all, align financial incentives to reward high-quality the balance set by the Affordable Care Act (Exhibit 1). care, and begin to organize the health system to ensure Only 25 percent of respondents felt states should have 3 better care coordination. An analysis of the Affordable more authority overall. A slim majority (51%) of lead- Care Act indicates that the significant insurance, pay- ers in academic and research institutions favor grant- ment, and delivery reform provisions included in the ing more power to the federal government for health law utilize these strategies and have the potential to reform than was incorporated in the law (Table 1). A bout the H ealth C are O pinion L eaders S urvey The Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey was conducted online within the United States by Harris Interactive, on behalf of The Commonwealth Fund, from April 6 to May 3, 2011, among 1,302 opinion leaders in health policy and innovators in health care delivery and finance. The final sample included 203 leaders for a response rate of 15.6 percent. For analytic purposes, respondents were grouped into four nonexclusive sectors: academic/research institutions (56%); health care delivery (23%); business/insurance/ other health care industry (22%); and government/labor/consumer advocacy (12%). Data from this survey were not weighted. A full methodology is available in Appendix A. H ealth C are O pinion L eaders ’ V iews on H ealth R eform and the R ole of S tates 3 Exhibit 1. The Affordable Care Act and the Role of States: Exhibit 2. The Affordable Care Act and the Role of States: Health Reform Overall Health Insurance Exchanges “In general, do you favor a stronger role for states or for the federal “Thinking about insurance coverage, do you favor a stronger role for states government than was incorporated in the Affordable Care Act? or for the federal government than was incorporated in the Affordable Please indicate the degree to which you believe states or the federal Care Act? Please indicate the degree to which you believe states government should have more authority regarding health reform overall.” or the federal government should have more authority regarding health insurance exchanges.” The federal government should have 14% The federal government should have 15% considerably more authority considerably more authority The federal government should have The federal government should have 27% 27% somewhat more authority somewhat more authority The law got the balance about right 29% The law got the balance about right 28% States should have somewhat 16% States should have somewhat 17% more authority more authority States should have considerably 9% States should have considerably more authority 11% more authority Not sure 4% Not sure 2% Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, May 2011. May 2011. A plurality of leaders believes the federal government Respondents are evenly divided over authority for should have somewhat or considerably more authority plans offered to Medicaid and subsidized populations. over health insurance exchanges. Key provisions in the Affordable Care Act expand eli- Opinion leaders were asked to indicate the degree to gibility in Medicaid to individuals or families earning which states or the federal government should have up to 133 percent of the federal poverty level and offer authority regarding the new health insurance premium subsidies to families earning up to four times 6 exchanges created under the Affordable Care Act. The the poverty level. Thirty-one percent of leaders law stipulates that states must establish new market- believe the law set an appropriate balance between places that offer small businesses and people without federal and state power regarding plans offered to employer coverage a choice of plans that meet new Medicaid and subsidized populations (Exhibit 3). 5 essential benefit standards. A plurality (42%) of lead- Thirty-six percent of all respondents favor a stronger ers believes the federal government should have some- role for the federal government, while 32 percent favor what or considerably more authority over the a stronger role for states. Views were fairly consistent exchanges (Exhibit 2). Twenty-eight percent of those across respondent categories (Table 2). surveyed believe the law got the balance about right, while another 28 percent believe states should have more authority. 4T he  C ommonwealth F und Exhibit 3. The Affordable Care Act and the Role of States: Exhibit 4. The Affordable Care Act and the Role of States: Plans Offered to Medicaid and Subsidized Populations Health Insurance Market Rules “Thinking about insurance coverage, do you favor a stronger role for states or “Thinking about insurance coverage, do you favor a stronger role for states or for the federal government than was incorporated in the Affordable Care Act? for the federal government than was incorporated in the Affordable Care Act? Please indicate the degree to which you believe states Please indicate the degree to which you believe states or the federal or the federal government should have more authority government should have more authority regarding plans offered to Medicaid regarding health insurance market rules.” and subsidized populations (up to four times poverty).” The federal government should have The federal government should have 16% 22% considerably more authority considerably more authority The federal government should have The federal government should have 20% somewhat more authority 28% somewhat more authority The law got the balance about right 31% The law got the balance about right 23% States should have somewhat States should have somewhat 17% 12% more authority more authority States should have considerably States should have considerably 15% more authority 15% more authority Not sure 2% Not sure 1% Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, May 2011. May 2011. Thirty-eight percent of those surveyed believe states Half of leaders favor granting the federal government should have a stronger role reviewing health insurance more power to set health insurance market rules. premium increases than what was incorporated into the Opinion leaders were asked whether they favored a Affordable Care Act (Exhibit 5). Twenty-nine percent stronger role for states or the federal government of leaders favor granting the federal government more regarding health insurance market rules. Under the authority over premium increases, while 28 percent law, new federal rules will prohibit insurers from restricting coverage or basing premiums on health sta- Exhibit 5. The Affordable Care Act and the Role of States: tus or gender. Half favor granting the federal govern- Review of Health Insurance Premium Increases ment somewhat or considerably more authority over “Thinking about insurance coverage, do you favor a stronger role for states or health insurance markets than was incorporated in the for the federal government than was incorporated in the Affordable Care Act? Please indicate the degree to which you believe states or Affordable Care Act (Exhibit 4). Twenty-three percent the federal government should have more authority regarding review of health insurance premium increases.” of respondents feel the law got the balance about right; 27 percent feel that states should have more authority. The federal government should have 13% considerably more authority A plurality of leaders favors granting more authority The federal government should have 16% somewhat more authority to states to review health insurance premium increases. The law got the balance about right 28% Private health insurance plans are now required to sub- States should have somewhat 19% mit justification of premium increases to the secretary more authority of Health and Human Services and state officials. States should have considerably 19% more authority Increases that are deemed “unreasonable” by either authority require submission and acceptance of a justi- Not sure 4% fication prior to implementation. Information on such increases is required to be posted on insurers’ Web sites. Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, May 2011. H ealth C are O pinion L eaders ’ V iews on H ealth R eform and the R ole of S tates 5 believe the law got the balance about right. balance about right, and another 41 percent feel the Respondents in business, insurance, and other indus- federal government should have somewhat or consid- tries (40%) and health care delivery (39%) favor grant- erably more authority. Results are fairly consistent ing states more authority relative to those in academic across respondent categories (Table 2). and research institutions (17%) (Table 2). Half of opinion leaders favor more federal authority Only 20 percent of respondents favor granting states over provider payment methods. more authority regarding the individual mandate. The Affordable Care Act contains several provisions Opinion leaders were asked to rate the degree to which designed to test and spread innovative provider pay- they believe states or the federal government should ment methods that aim to improve quality of care have more authority regarding the individual mandate while reducing costs. Provisions include the creation provision of the Affordable Care Act. This require- of a new Center for Medicare and Medicaid ment, set to take effect in 2014, requires individuals to Innovation in 2011 and an Independent Payment carry adequate health insurance coverage or pay a pen- Advisory Board in 2014. The federal government will alty. In exchange, insurers will be banned from also increase its payment levels for primary care under restricting coverage or basing premiums on health sta- Medicare and Medicaid, utilize the accountable care tus or gender. The individual mandate remains a con- organization model of care delivery, and encourage the troversial component of the new law and the basis for adoption of patient-centered medical homes. several legal challenges now working their way Half (50%) of leaders favor a stronger role for through the federal court system. the federal government regarding provider payment Only 20 percent of opinion leaders favor a methods (Exhibit 7). Twenty-seven percent feel the stronger role for states regarding the individual man- balance between federal and state responsibility for date than was incorporated in the Affordable Care Act provider payment under the law is about right, while (Exhibit 6). Thirty-six percent feel the law got the another 21 percent favor granting states more authority. Exhibit 6. The Affordable Care Act and the Role of States: Exhibit 7. The Affordable Care Act and the Role of States: The Individual Mandate Provider Payment Methods “Thinking about insurance coverage, do you favor a stronger role for states or “Thinking about payment and delivery system reform, do you favor a stronger for the federal government than was incorporated in the Affordable Care role for states or for the federal government than was incorporated in the Act? Please indicate the degree to which you believe states or the federal Affordable Care Act? Please indicate the degree to which you believe government should have more authority regarding the individual mandate.” states or the federal government should have more authority regarding provider payment methods.” The federal government should have The federal government should have 25% 21% considerably more authority considerably more authority The federal government should have The federal government should have 16% 29% somewhat more authority somewhat more authority The law got the balance about right 36% The law got the balance about right 27% States should have somewhat States should have somewhat 10% 9% more authority more authority States should have considerably States should have considerably more authority 10% more authority 12% Not sure 4% Not sure 4% Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, May 2011. May 2011. 6T he  C ommonwealth F und Forty percent of respondents favor more federal Exhibit 9. Implementation of the Affordable Care Act authority regarding medical malpractice. at the State Level “How concerned are you with the following barriers to successful Opinion leaders were asked whether they favor a implementation of the Affordable Care Act at the state level?” stronger federal or state role regarding medical mal- practice than was incorporated into the Affordable Concerned Very concerned Care Act. Overall, 40 percent of respondents favor The current fiscal situation and 11% granting the federal government somewhat or consid- budgetary pressures in many states 78% 89% erably more authority (Exhibit 8). Twenty-one percent State political resistance and 22% 56% 78% feel the law got the balance about right. Leaders in pending legal challenges health care delivery were much less likely to favor the Technical knowledge and 35% 36% 71% balance set by the law and much more likely to favor capacity of state agencies either more federal or state authority (Table 3). Staffing levels at state agencies 30% 39% 69% Nearly nine of 10 health care opinion leaders are con- Organization and performance of 34% 33% 67% cerned or very concerned about the current fiscal situ- health care delivery systems in states ation and budgetary pressures in many states as barri- Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, ers to successful implementation of the Affordable May 2011. Care Act. More than 70 percent indicated concern over state Opinion leaders were asked to indicate their concern political resistance and pending legal challenges (78%) about several perceived barriers to successful imple- and technical knowledge and capacity of state agencies mentation of the Affordable Care Act at the state level. (71%). Staffing levels at state agencies (69%) and the Nearly nine of 10 (89%) of those surveyed are con- organization and performance of health care delivery cerned or very concerned about the current fiscal situa- systems in states (67%) also rank as significant con- tion and budgetary pressures in states (Exhibit 9). cerns for a large majority of respondents. Sixty-two percent of respondents support creation of a Exhibit 8. The Affordable Care Act and the Role of States: Medical Malpractice federal health insurance exchange in addition to state “Thinking about payment and delivery system reform, do you favor a stronger health insurance exchanges. role for states or for the federal government than was incorporated in the Affordable Care Act? Please indicate the degree to which Some policymakers have argued that a federal health you believe states or the federal government should have more authority regarding medical malpractice.” insurance exchange should be created as a complement or alternative to state exchanges, which will become The federal government should have considerably more authority 22% operable in 2014. Such an exchange could serve The federal government should have employees at multistate firms or people with family 18% somewhat more authority members in different states. Sixty-two percent of sur- The law got the balance about right vey respondents support or strongly support creation 21% of a federal health insurance exchange in addition to States should have somewhat 16% the state exchanges (Exhibit 10). Leaders in academic more authority institutions and health care delivery support the cre- States should have considerably more authority 15% ation of a federal exchange at similar rates (64% and 65%, respectively), while those in business, insurance, Not sure 10% and other health care industries (48%) are much less likely to do so (Table 5). Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, May 2011. H ealth C are O pinion L eaders ’ V iews on H ealth R eform and the R ole of S tates 7 Exhibit 10. Support for a Federal Health Insurance Exchange Exhibit 11. Affordable Care Act Substitutes “Some policymakers have argued that a federal health insurance exchange “Recently, several policymakers have proposed legislation allowing states to opt should be created as a complement or alternative to state exchanges out of certain Affordable Care Act provisions and devise their own insurance for enrollees of, for example, multistate firms or people with family members coverage systems as early as 2014, provided they meet certain requirements. in different states. Please indicate the degree to which you support the These include providing ‘coverage that is at least as comprehensive,’ creation of a federal health insurance exchange in addition to operable ‘cost-sharing protections . . . that are at least as affordable,’ and ‘coverage to at state health insurance exchanges.” least a comparable number of residents’ as would have occurred under the law. State-initiated reforms also may not add to the federal budget deficit. Please Not sure indicate the degree to which you support such state reform substitutes.” Strongly oppose 4% 8% Not sure 3% Strongly Strongly Oppose support Strongly 8% support 26% oppose 14% 15% Neither support nor oppose 17% Oppose Support 17% Support 36% 35% Neither support nor oppose Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, 18% May 2011. Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, Mixed support for state reform waivers and substitutes. May 2011. Recently, several policymakers have proposed legisla- and creation of insurance exchanges with premium tion allowing states to opt out of certain Affordable subsidies ahead of the original timelines outlined in Care Act provisions and devise their own insurance the law. Health care opinion leaders are strongly sup- coverage systems as early as 2014, provided they meet portive of allowing early implementation of the law, certain requirements. These include providing “cover- with 82 percent either supporting or strongly age that is at least as comprehensive,” “cost-sharing protections … that are at least as affordable,” and Exhibit 12. Early Implementation of the Affordable Care Act “coverage to at least a comparable number of resi- “Some states have indicated a capacity and willingness to implement key 7 provisions of the Affordable Care Act such as expansion of Medicaid eligibility dents” as would have occurred under the law. State- and creation of insurance exchanges with premium subsidies ahead of the initiated reforms also may not add to the federal bud- original timelines outlined in the law. Please indicate the degree to which you support allowing states to accelerate implementation of the law with full federal get deficit. support (e.g., accelerated funding for insurance premium subsidies).” Overall, 49 percent of leaders support or Strongly strongly support allowing states to make such substitu- oppose 3% tions (Exhibit 11). Those in health care delivery (57%) Not sure Oppose 1% and business, insurance, and other health care indus- 5% Neither support tries (55%) reported support at the highest rates, while nor oppose 8% those in academic and research institutions (43%) were Strongly less enthusiastic (Table 6). support 35% More than eight of 10 respondents support allowing Support early implementation of the Affordable Care Act. 47% Some states have indicated a capacity and willingness to implement key provisions of the Affordable Care Act such as expansion of Medicaid eligibility Source: Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey, May 2011. 8T he  C ommonwealth F und supporting the proposal (Exhibit 12). Only 8 percent of more authority regarding health insurance market rules all respondents do not support allowing states to accel- and provider payment methods; two of 10 favor grant- erate implementation with full federal support. ing states more power over the individual mandate provision contained in the law. Six of 10 leaders sup- THE PATH TO A HIGH PERFORMANCE port creating a federal health insurance exchange in HEALTH SYSTEM addition to state exchanges. Opinion leaders expressed The Affordable Care Act has the potential to signifi- concern about barriers to successful implementation, cantly transform the American health care system including the current fiscal situation and budgetary through a mix of public and private coverage expan- pressures in many states. Despite these concerns and sion and provider payment reform initiatives. The law ongoing challenges, more than 80 percent of leaders creates several specific new requirements for states, support allowing states to implement key provisions including expansion of Medicaid eligibility, creation of ahead of the original timelines outlined in the law. state-based health insurance exchanges by 2014, and Commonwealth Fund research and analysis increased regulation of private health insurance indus- has suggested that the enactment and successful imple- try practices. The federal government, in turn, is pri- mentation of the Affordable Care Act at both the fed- marily responsible for partnering with states in cover- eral and state levels can help the nation enter a new era age expansion efforts, rapidly testing and spreading of health care. However, reform remains a work in new provider payment methods, and supporting initia- progress, and cooperation and coordination among fed- tives that seek to transform the health care delivery eral and state officials is essential to successfully real- system. izing the potential of reform. To that end, diligently When asked about the relative power of states monitoring both reform efforts and health system per- and the federal government over health reform, 41 per- formance at the federal, state, and local levels can help cent of health care opinion leaders think the federal ensure a proper balance among levels of government government should have more authority and 29 percent and lead to a health system that produces the best out- favor the balance set by the Affordable Care Act. Half comes for all Americans. of leaders support granting the federal government H ealth C are O pinion L eaders ’ V iews on H ealth R eform and the R ole of S tates 9 N otes 1 K. Davis, A New Era in American Health Care: Realizing the Potential of Reform (New York: The Commonwealth Fund, June 2010). 2 The Commonwealth Fund Commission on a High Performance Health System, Framework for a High Performance Health System for the United States (New York: The Commonwealth Fund, Aug. 2006). 3 The Commonwealth Fund Commission on a High Performance Health System, Keeping Both Eyes on the Prize: Expanding Coverage and Changing the Way We Pay for Care Are Essential to Make Health Reform Work for Families and Businesses (New York: The Commonwealth Fund, Nov. 2009). 4 Davis, A New Era, 2010. 5 K. Davis, S. Guterman, S. R. Collins, K. Stremikis, S. Rustgi, and R. Nuzum, Starting on the Path to a High Performance Health System: Analysis of the Payment and System Reform Provisions in the Patient Protection and Affordable Care Act of 2010 (New York: The Commonwealth Fund, Sept. 2010). 6 Davis, Guterman, Collins, Stremikis, Rustgi, and Nuzum, Starting on the Path, 2010. 7 J. E. McDonough, “Wyden–Brown and the Health Law: A Match Made in Heaven or Limbo?” Kaiser Health News, March 8, 2011. 10T he  C ommonwealth F und A ppendix A. M ethodology This survey was conducted online by Harris Interactive on behalf of The Commonwealth Fund among 203 opinion leaders in health policy and innovators in health care delivery and finance within the United States from April 6 to May 3, 2011. Harris Interactive sent out individual e-mail invitations to the entire panel con- taining a password-protected link, and a total of five reminder e-mails were sent to those that had not responded. No weighting was applied to these results. The initial sample for this survey was developed using a two-step process. The Commonwealth Fund and Harris Interactive jointly identified a number of experts across different professional sectors with a range of perspectives based on their affiliations and involvement in various organizations. Harris Interactive then conducted an online survey with these experts, asking them to nominate others within and outside their own fields whom they consider to be leaders and innovators in health care. Based on the result of the survey and after careful review by Harris Interactive, The Commonwealth Fund, and a selected group of health care experts, the sample for this poll was created. The final list included 1,246 individuals. In 2006, The Commonwealth Fund and Harris Interactive joined forces with Modern Healthcare to add new members to the panel. The Commonwealth Fund and Harris Interactive were able to gain access to Modern Healthcare’s database of readers. The Commonwealth Fund, Harris Interactive, and Modern Healthcare identified readers in the database that were considered to be opinion leaders and invited them to participate in the survey. This list included 1,467 people. At the end of 2006, The Commonwealth Fund and Harris Interactive removed those panelists who did not respond to any previous surveys. In 2007 recruitment for the panel continued with Modern Healthcare recruiting individuals through their Daily Dose newsletter. In addition, Harris Interactive continued to recruit leaders by asking current panelists to nominate other leaders. The final panel size for the Affordable Care Act and state role survey included 1,302 leaders. With this survey, we are using a new definition of the panel. Two hundred three of these panelists completed the survey, for a 15.6 percent response rate. With a pure probability sample of 203 adults, one could say with a 95 percent probability that the overall results have a sampling error of +/– 6.88 percentage points. However, that does not take other sources of error into account. This online survey is not based on a probability sample, and therefore, no theoretical sampling error can be calculated. The data in this brief are descriptive in nature. They represent the opinions of the health care opinion leaders interviewed and are not projectable to the universe of health care opinion leaders. H ealth C are O pinion L eaders ’ V iews on H ealth R eform and the R ole of S tates 11 A bout the A uthors Kristof Stremikis, M.P.P., is senior research associate for the president of The Commonwealth Fund. Previously, he was a graduate student researcher in the School of Public Health at the University of California, Berkeley, where he evaluated various state, federal, and global health initiatives while providing economic and statistical support to faculty and postdoctoral fellows. He has also served as consultant in the director’s office of the California Department of Healthcare Services, where he worked on recommendations for a pay-for-performance system in the Medi-Cal program. Mr. Stremikis holds three undergraduate degrees in economics, political science, and history from the University of Wisconsin at Madison. In May 2008, he received a Master of Public Policy degree from the Goldman School at the University of California, Berkeley. He can be e-mailed at ks@cmwf.org. Karen Davis, Ph.D., is president of The Commonwealth Fund. She is a nationally recognized economist with a distinguished career in public policy and research. In recognition of her work, Ms. Davis received the 2006 AcademyHealth Distinguished Investigator Award. Before joining the Fund, she served as chairman of the Department of Health Policy and Management at The Johns Hopkins Bloomberg School of Public Health, where she also held an appointment as professor of economics. She served as deputy assistant secretary for health policy in the Department of Health and Human Services from 1977 to 1980, and was the first woman to head a U.S. Public Health Service agency. A native of Oklahoma, she received her doctoral degree in economics from Rice University, which recognized her achievements with a Distinguished Alumna Award in 1991. Ms. Davis has published a number of significant books, monographs, and articles on health and social policy issues, including the landmark books Health Care Cost Containment; Medicare Policy; National Health Insurance: Benefits, Costs, and Consequences; and Health and the War on Poverty. She can be e-mailed at kd@cmwf.org. Rachel Nuzum, M.P.H., is assistant vice president for Federal Health Policy at The Commonwealth Fund. She is responsible for implementing the Fund’s national policy strategy for improving health system performance, including building and fostering relationships with congressional members and staff and members of the exec- utive branch to ensure that the work of the Fund and its Commission on a High Performance Health System inform their deliberations. Previously, she was a legislative assistant for Senator Maria Cantwell (D–Wash.) and served as a David Winston Health Policy Fellow in Senator Jeff Bingaman’s (D–N.M.) office. Before arriving in Washington, D.C., she served former Governor Roy Romer of Colorado in the office of Boards and Commissions and worked as a health planner in west central Florida. She holds a B.A. in political science from the University of Colorado and an M.P.H. in health policy and management from the University of South Florida. She can be e-mailed at rn@cmwf.org. Edward L. Schor, M.D., is vice president of The Commonwealth Fund, where he directs the State Health Policy and Practices program. The goal of that program is to help state leaders create the policies and programs that will lead to higher health system performance, especially for low-income populations, emphasizing the integra- tion of services to achieve better coordination of care and efficiency. He previously directed the Fund’s Child Development and Preventive Care program. Dr. Schor is a pediatrician and has held a number of positions in pedi- atric practice, academic pediatrics, health services research, and public health. Prior to joining The Commonwealth Fund he was medical director for Family and Community Health in the Iowa Department of Public Health. Editorial support was provided by Deborah Lorber.